Abstract: Children of anxious mothers are at risk for social-emotional difficulties and disturbed, early interactions with their mother may account for some of the risk. This study evaluated the association between maternal anxiety, features of mother-infant interactions, and infants' emotion regulation during stressful situations (still-face, play with a stranger). Thirty-four anxiety-disordered mothers of 6-month-old infants and 59 typical dyads comprised the sample. Dyads were filmed during free play, teaching, care giving, and face-to-face play; and monadic (e.g., maternal sensitivity, infant affect) and dyadic measures (e.g., synchrony) were derived by global or time-event coding of the films. Results indicate that, compared to controls, more anxious mothers showed exaggerated behavior with their infant during free play and teaching, and infants of anxious mothers were less likely to show negative affect during the still-face and stranger challenges. We conclude that anxious maternal behavior reflects the hyperarousal that is characteristic of most anxiety disorders; and infants of anxious mothers and controls show differences in the manner in which they cope with social challenges.
Abstract: BACKGROUND: A key protein in maintaining neuronal integrity throughout the life span is brain-derived neurotrophic factor (BDNF). The BDNF gene is characterized by a functional polymorphism, which has been associated with stress-related disorders such as anxiety-related syndromes and depression, prompting us to examine individual responses by Genotype and Sex to a standardized social stress paradigm. Gender differences in BDNFxstress responses were posited because estrogen induces synthesis of BDNF in several brain regions. METHODS: 97 university students (51 females and 46 males) participated in a social stress procedure (Trier Social Stress Test, TSST). Indices of stress were derived from repeated measurement of cortisol, blood pressure, and heart rate during the TSST. All subjects were genotyped for the Val66Met polymorphism. RESULTS: Tests of within-subject effects showed a significant three-way interaction (SPSS GLM repeated measures: Time (eight levels)xBDNF (val/val, val/met)xSex: p=0.0002), which reflects gender differences in the pattern of cortisol rise and decline during the social challenge. In male subjects, val/val homozygotes showed a greater rise in salivary cortisol than val/met heterozygotes. In female subjects, there was a trend for the opposite response, which is significant when area under the curve increase (AUCi) was calculated for the val/val homozygotes to show the lowest rise. Overall, the same pattern of results was observed for blood pressure and heart rate. CONCLUSIONS: These results indicate that a common, functionally significant polymorphism in the BDNF gene modulates HPA axis reactivity and regulation during the TSST differently in men and women. Findings may be related to gender differences in reactivity and vulnerability to social stress.
Abstract: OBJECTIVE: To study whether the sex of the offspring is related to increasing parental age, gravidity, and parity, hypothesizing an altered male-to-female sex ratio with the advancing parental age. DESIGN: A large retrospective cohort study. SETTING: The study analyzed birth records of Hadassah Hebrew University Medical Center in Jerusalem from June 2003 to December 2006. PATIENT(S): 35,837 birth records were analyzed including 941 multifetal deliveries, excluding foreign inhabitants (n = 744), missing data for the main study outcome (n = 2) and parturients over 50 years to control for egg donation (n = 26). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Male-to-female sex ratio. RESULT(S): The male-to-female sex ratio of all the newborns was 1.05. This ratio did not change significantly with either maternal or paternal age. Neither gravidity nor parity affected the male-to-female ratio. The only factor that affected the regression of sex ratio was the length of gestation. CONCLUSION(S): Sex ratio at birth is remarkably constant. No association was found between parental age or birth order and neonatal sex ratio.
Abstract: Through its receptor Kit (CD117), stem cell factor (SCF) critically regulates human mast cell (MC) differentiation, survival, priming, and activation. The dominance of SCF in setting these parameters compels stringent contra-regulation to maintain a balanced MC phenotype. We have synthesized a library of bispecific Ab fragments to examine the effect of linking Kit with CD300a. In this study, we report that CD300a exerts a strong inhibitory effect on Kit-mediated SCF-induced signaling, consequently impairing MC differentiation, survival, and activation in vitro. This effect derives from Kit-mediated tyrosine phosphorylation of CD300a and recruitment of the SHIP-1 but not of SH2-containing protein phosphatase 1. CD300a inhibits the constitutive activation of the human leukemic HMC-1 cells but not their survival. Finally, CD300a abrogates the allergic reaction induced by SCF in a murine model of cutaneous anaphylaxis. Our findings highlight CD300a as a novel regulator of Kit in human MC and suggest roles for this receptor as a suppressor of Kit signaling in MC-related disorders.
Abstract: BACKGROUND: Mast cells activation through FcepsilonRI cross-linking has a pivotal role in the initiation of allergic reactions. The influence of this activation on programmed cell death of human mast cells has not yet been clarified. This study evaluates the influence of IgE-dependent activation alone and in synergy with TRAIL on the expression of molecules involved in the apoptotic signal transduction. METHODS: Human cord blood derived mast cells (CBMC) were cultured with myeloma IgE followed by activation with anti-human IgE. The expression of proteins involved in apoptotic signal transduction was assessed by immunoblot analysis. To test the effect of activation on a pro-apoptotic stimulus, activated, IgE-treated and resting CBMC were incubated with TRAIL, or in a medium with suboptimal concentrations of stem cell factor (SCF). RESULTS: In accordance with a previous study of ours, it was found that IgE-dependent activation increased TRAIL-induced caspase-8 and caspase-3 cleavage. However, it did not have a significant influence on CBMC death induced by SCF withdrawal. IgE-dependent activation increased the expression of FLIP and myeloid cell leukemia 1 (MCL-1) anti-apoptotic molecules as well as the pro-apoptotic one, BIM. In addition, a decrease in BID expression was observed. TRAIL could reverse the increase in FLIP but did not influence the upregulation of MCL-1 and of BIM. CONCLUSIONS: These findings suggest that IgE-dependent activation of human mast cells induces an increase in both pro-survival and pro-apoptotic molecules. We therefore hypothesized that IgE-dependent activation may regulate human mast cell apoptosis by fine-tuning anti-apoptotic and pro-apoptotic factors.
Abstract: OBJECTIVE: Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate the incidence of bacteriuria following labor and to identify risk factors predisposing to this condition. METHODS: Three hundred and fifty parturients were recruited, 301 were included in the analysis. Women receiving antibiotic drugs during delivery were excluded. Urine cultures were obtained from the study group before delivery and prior to discharge. Data regarding management of labor was collected prospectively. RESULTS: Positive urine cultures were present on admission in 5.4% of women, whereas 12.9% had a positive urine culture at discharge (p < 0.003). Bacteriuria was acquired during labor in 12.7% of patients who had negative cultures on admission. Escalating number of digital vaginal examinations (p = 0.04), recurrent bladder catheterization (p = 0.05), duration of epidural anesthesia (p = 0.002), and vacuum delivery (p = 0.02) correlated significantly with an increased risk for acquiring bacteriuria. CONCLUSION: Labor is a bacteriuric event. Iatrogenic interventions can predispose parturients with sterile urine cultures to postpartum bacteriuria.
Abstract: Neonate erythrocytes are more susceptible to oxidizing drugs than adults; however, there are controversial reports in the literature regarding the total antioxidant capacity of neonate blood. Stable nitroxide radicals (NRs) are reduced by blood and some other biological materials to the corresponding hydroxylamines. The kinetics of the nitroxide's disappearance using electron paramagnetic resonance (EPR) spectroscopy, provides useful biochemical and biophysical information about the antioxidant properties of biological systems. In order to investigate the antioxidant properties in the newborn's blood, we applied this novel method on 38 umbilical vein blood samples and 40 healthy adults. The NR, 5-Dimethylaminonaphthalene-1-sulfonyl-4-amino-2,2,6,6,-tetramethyl-piperidine-oxyl (R), was used for this purpose. Ascorbate is the only known natural antioxidant that reduces R. We found that the reduction rates of R in neonate's whole blood are significantly higher (P < 0.001) than the reduction rates of R in adult's whole blood. However, there were no significant differences in the antioxidant capacity between the two groups. Newborn's blood has significantly higher ability to deal with oxidative stress, caused by R, in comparison with adult blood. We suggest that the system that responds to the recycling of ascorbate is more efficient in neonate blood than in adult's blood.
Abstract: The ability of Staphylococcus aureus to invade and survive within host cells is believed to contribute to its propensity to cause persistent and metastatic infections. In addition, S. aureus infections often are associated with atopic diseases such as dermatitis, rhinitis, and asthma. Mast cells, the key cells of allergic diseases, have a pivotal role in innate immunity and have the capacity of phagocytosis, and they can destroy some pathogenic bacteria. However, little is known about the ability of some other bacteria to survive and overcome mast cell phagocytosis. Therefore, we were interested in evaluating the interplay between mast cells and S. aureus. In this study, we show that human cord blood-derived mast cells (CBMC) can be infected by pathogenic S. aureus. S. aureus displayed a high adherence to mast cells as well as invasive and survival abilities within them. However, when infections were performed in the presence of cytochalasin D or when CBMC were preincubated with anti-Toll-like receptor 2 (TLR2) or anti-CD48 antibodies, the invasiveness and the inflammatory response were abrogated, respectively. Furthermore, we observed an increase of TLR2 and CD48 molecules on CBMC after S. aureus infection. The infection of CBMC with S. aureus also caused the release of tumor necrosis factor alpha (TNF-alpha) and interleukin-8 (IL-8). Both live and killed S. aureus organisms were found to trigger TNF-alpha and IL-8 release by CBMC in a time-dependent manner. Cumulatively, these findings suggest that S. aureus internalizes and survives in mast cells. This may play an important role in infections and in atopic diseases associated with S. aureus.
Abstract: OBJECTIVE: The objective of this study was to assess the correlation between patients' view of the consultation and the assessment of an auditing physician on the same consultation. METHODS: A prospective study in military clinics was conducted. A board-certified family physician made a real-time semistructured assessment of the medical consultation. At the end of it, the patient was asked to fill in the Consultation Satisfaction Questionnaire. The degree of correlation between patients' satisfaction from consultation and the scores given by the auditing physician was evaluated. RESULTS: Twelve primary care physicians were evaluated. A total of 117 (76.5%) of 153 patients returned their questionnaires. A positive correlation was found between physician's communication skills and general satisfaction (r = 0.614), professional care (r = 0.367), and depth of relationship (r = 0.275) calculated from the Consultation Satisfaction Questionnaire. No correlation was found between patient satisfaction and other consultation skills. CONCLUSIONS: Good communication skills may enhance patient satisfaction. It may be advisable to investigate whether a training program to enhance the physician's communication skills can improve patient satisfaction.
Abstract: To analyse the use of a free, public, perinatal internet consultation service, 2000 consultations provided by university hospital staff were evaluated over 30 months. Ninety five percent of the questioners were women, and 62% of them were primiparous. The average response rate was 2.3 audience responses per question. Fifty-two percent of the consultations were related to labour and delivery, 23% were related to pregnancy complications, 16% were related to prenatal diagnosis, and 7% were related to the puerperium period. We conclude that medical consultation forums provide an additional way of delivering inexpensive, accessible, fast, and convenient healthcare services.
Abstract: Pregnancy is an immunological mystery. The conceptus survives and develops despite being an allogenic transplant, in terms of classical immunology. Natural killer cells are the predominant immune-cell population in the early human placenta. The role of these cells in human pregnancy is not fully established, yet it presumed they are required for placental development and local immunomodulation at the maternal-fetal interface. The purpose of this review is to examine recent progress in characterizing natural killer cells, the quantitative and qualitative changes that occur in these cells through pregnancy. We will also point out the possible role of these cells in the maintenance of normal pregnancy and the pathogenesis of recurrent pregnancy loss.
Abstract: Achalasia is a motor disorder of the esophageal smooth muscle in which the lower esophageal sphincter does not relax normally with swallowing, and the esophageal body undergoes nonperistaltic contractions. The underlying abnormality is the loss of intramural neurons. Achalasia affects men and women of all ages. Dysphagia, chest pain, and regurgitation are the main symptoms. Information on the effects of achalasia on pregnancy outcome and the effects of pregnancy on the natural course of achalasia is limited. Two studies, including 30 patients altogether, and several case reports have been published. Treatment options include nitrates, calcium channel antagonists, botulinum toxin injection, pneumatic dilation, and esophagomyotomy.
Abstract: BACKGROUND: This prospective, non-randomized study compared post-void residual volume in laboring and postpartum women with or without epidural analgesia. METHODS: The study was conducted over 1 year with institutional review board approval. Parturients were recruited in early labor and self-selected to either the study (with epidural) or control (without epidural) group. Post-void residual volume was compared between groups, using transabdominal ultrasound during labor, and on postpartum day 1 and 2. Main outcome measure was intrapartum residual bladder volume. RESULTS: Thirty patients were recruited to each group. During labor, residual bladder volume was significantly larger in the epidural group compared with the non-epidural group [median (range)] 240 (12-640), ml vs. 45 (13-250) ml, respectively, P < 0.001], but was similar on postpartum day 1 and 2. Twenty-five (83%) women with epidural analgesia required bladder catheterization during labor vs. one (3.3%) without (P < 0.0001). CONCLUSION: The greater post-void residual volume and increased inability to void in parturients with epidurals suggests that epidural analgesia plays a role in intrapartum urinary retention.
Abstract: The damage created by an earthquake can overwhelm local health services, and damage to clinics and hospitals can render them useless. After an earthquake, even undamaged medical facilities cannot be used for a period of time if there is a risk of aftershocks and collapse. In such a situation, there may be calls for international health teams--but what constitutes the optimal medical aid a few days after the event? Does a military field hospital fill the "gap" in the local healthcare system? On 12 November 1999, a 7.2 magnitude earthquake struck Duzce, Turkey. All of the medical activities of the responding Israeli Defense Forces (IDF) mission team field hospital in Duzce, Turkey were recorded and evaluated. A total of 2,230 patient contacts occurred at the field hospital during the nine days it operated. Most of the patients who presented (90%) had non-traumatic medical, pediatric, or gynecological problems unrelated to the earthquake. The IDF hospital offered medical care provided by specialists, hospitalization, and surgical abilities, which Duzce's hospitals could not offer until two weeks after the earthquake. These results strengthen the importance of a multidisciplinary, versatile, field hospital as an aid to an earthquake-affected population during the first few weeks after an earthquake.
Abstract: Placenta accreta may be suspected prior to surgery, but the actual diagnosis is only confirmed at surgery. This prospective and observational study was performed to assess whether preparations should be made for potential massive blood loss prior to Caesarean surgery in all patients with suspected placenta accreta. Patients were classified as high or low suspicion for placenta accreta based on ultrasonography and clinical factors. Among 28 suspected cases of placenta accreta, diagnosis was confirmed at surgery in 50% (12/17 high and 2/11 low suspicion) cases. Hysterectomy was only performed in the 12 high suspicion patients with placenta accreta (p < 0.001). High suspicion patients required more blood transfusions: mean(SD) 6.5 (7.0) units vs 1.09 (1.1) units, p = 0.017. Anaesthetists should be prepared for major haemorrhage in all cases of suspected placenta accreta, although use of a system to grade level of suspicion may identify those at greater risk.
Abstract: OBJECTIVE: The purpose of the study was to characterize the perinatal outcome of pregnancies complicated by placenta accreta. METHODS: We conducted a case-control analysis of all deliveries between the years 1990 and 2000 that were complicated by placenta accreta. Perinatal variables included in the analysis were gestational age at delivery, birth weight, Apgar scores, and perinatal mortality. Statistical analysis was performed using both the unpaired and paired approach. P <.05 was considered significant. RESULTS: The study encompassed 34,450 deliveries, from which 310 cases of placenta accreta were diagnosed (0.9%) and compared with 310 matched controls. In the pregnancies complicated by placenta accreta, we found a statistically significant increase in preterm deliveries (10.7% versus 1%, P <.001, odds ratio 12.1, 95% confidence interval 3.7-39.9) and small-for-gestational-age babies (27.3% versus 14%, P <.001, odds ratio 5.05, 95% confidence interval 1.46-3.28). CONCLUSION: Pregnancies complicated by placenta accreta are at increased risk for perinatal adverse outcome. We speculate that these findings may arise from pathological implantation of the placenta, resulting in interference with normal fetal growth.
Abstract: BACKGROUND: Elevated mid-trimester human chorionic gonadotropin (hCG) is associated with adverse maternal and perinatal outcome. The aims of the study were to evaluate the association between elevated hCG, fetal pathological arterial waveforms and maternal and perinatal complications. METHODS: Pulsatility indices (PI) of middle cerebral artery (MCA) and umbilical artery (UA) were determined prospectively in 121 consecutive patients with abnormal maternal serum hCG (> 2.5 MoM). Each patient had four US scans during pregnancy. Patients with known structural or chromosomal anomalies were excluded. RESULTS: Of 121 women with hCG > 2.5 MoM, 36/121(29.6%) had hCG between 2.5 and 3.0 MoM, 35/121(28.9%) had hCG between 3.0 and 3.5 MoM, 21/121(17.3%) had hCG of 3.5-4.0 MoM, 17/121(14.1%) had hCG levels between 4.0 and 4.5 MoM, and 12/121(9.9%) had hCG > 4.5 MoM. Middle cerebral artery PI was significantly lower in women with hCG > 4.0 MoM between 28 and 36 weeks' gestation, but not between 18 and 27 weeks' gestation. No differences of MCA PI were found when the cut-off point of hCG was 3.5. Women with hCG levels > 4.0 MoM had a significantly higher rate of preterm deliveries, cesarean sections, higher rate of Apgar scores < 7 and a significantly lower mean birth weight in comparison with women with hCG < 4.0 MoM. The prevalence of PIH and preeclampsia and perinatal death were found to be higher among patients with hCG levels > 4.0 MoM, although not significantly. No differences were found at hCG levels less than 4.0 MoM. CONCLUSIONS: In pregnancies with mid-trimester hCG > 4.0 MoM, redistribution of cerebral blood flow is expressed after 28 weeks' gestation. These pregnancies have higher rates of maternal and neonatal complications as compared to pregnancies with lower hCG levels.
Abstract: OBJECTIVE: The risk of perinatal death associated with labor after previous cesarean section appears higher than with a repeated cesarean section. On the other hand, repeated cesarean sections are associated with increased maternal morbidity and mortality from placental pathologic conditions (previa or accreta) on subsequent pregnancies. The study was undertaken to analyze the decision for a trial of labor or a repeated cesarean section, after a prior cesarean section, with varying desire for an additional pregnancy. STUDY DESIGN: A model was formulated using a decision tree, based on the reported risks of the two approaches. Sensitivity analysis was performed over a variety of probabilities (eg, chance of uterine rupture or neonatal death, chance of rescue cesarean section, desire for an additional pregnancy) and utilities (eg, use of hysterectomy or neonatal death). RESULTS: The model favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10% to 20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit. The model was robust over a wide range of assumptions. CONCLUSION: An optimal decision for a trial of labor or a repeated cesarean section is substantially determined by the wish for future pregnancies. The default option of a repeated cesarean section is not directly applicable in populations in which family planning often extends over two children.
Abstract: The kinetics of reduction of the radical R*, 5-dimethylaminonaphthalene-1-sulfonyl-4-amino-2,2,6,6-tetramethyl-1-piperidine-oxyl by blood and its components were studied using the EPR technique. The results demonstrate that R* is adsorbed to the outer surface of the membrane and does not penetrate into the erythrocytes. A series of control experiments in PBS demonstrate that ascorbate is the only natural reducing agent that reacts with R*. The observed first order rate of disappearance of the nitroxide radical k, is: k(blood) > k(eryth) > k(plasma) and k(blood) approximately = k(eryth) + k(plasma). The results demonstrate that: a. The erythrocytes catalyze the reduction of R* by ascorbate. b. The rate of reduction of the radical is high though it does not penetrate the cells. c. In human erythrocytes there is an efficient electron transfer route through the cell membrane. d. The study points out that R* is a suitable spin label for measuring the reduction kinetics and antioxidant capacity in blood as expressed by reduction by ascorbate.
Abstract: On August 17, 1999, an earthquake of 7.4 magnitude struck Turkey, resulting in the destruction of the cities Golcuk, Izmit, Adapazari, and Yalova. Three days later, the Israel Defense Force Field Hospital arrived at Adapazari, serving as a reinforcement hospital until the rehabilitation of the local medical facilities. Surgical services in the field hospital were supplied by general, orthopedic, and plastic surgeons. The authors evaluated all soft-tissue injuries managed at the hospital and assessed the need for plastic surgery services in a crisis intervention field hospital. Information was gathered regarding soft-tissue injuries throughout the activity of the hospital. In addition, patients' charts, operations' reports, and entry and evacuation logs were reviewed for all patients accepted and treated in the field hospital. Interviews of patients, local physicians, and citizens of Adapazari were performed to evaluate the medical situation in the first 3 days after the earthquake. A total of 1205 patients were treated by the field hospital in Adapazari; 138 (11.45 percent) of these patients sought aid for isolated soft-tissue injuries, 105 of which (76.09 percent) were earthquake-related. Twenty (51.28 percent) of the operations performed in the hospital were to treat soft-tissue injuries; 1.49 percent of all patients underwent minor surgical manipulations by the plastic surgeon on staff. Plastic surgery patients occupied 13.6 percent of the hospital beds. In conclusion, the authors find it beneficial to supply plastic surgery services at a field hospital in an earthquake situation.
Abstract: An earthquake striking a highly populated area is likely to cause a mass casualty situation for even the most advanced trauma center. If the local medical teams are injured and the hospitals are damaged beyond immediate repair, external intervention is needed. In the Turkish earthquake crisis, Israel was one of many states to deploy a field hospital to the crisis site. This was set up in Adapazari, the second most severely hit city in terms of the amount of damage. The hospital provided advanced surgical and medical facilities, including laparotomy, cesarean section, and intensive care surveillance. These facilities require sophisticated laboratory and radiology services, including hematology, chemistry, microbiology, and blood bank. The speed with which the hospital must be assembled and transported to be efficient and the basic conditions of a field hospital dictate specific considerations regarding diagnostic auxiliary equipment. Considerations in choosing this equipment, problems encountered during installation, and recommendations for the future are presented.
Abstract: Erythrocyte aggregation was determined by a novel method enabling the quantification of the aggregation process in whole blood. Blood samples of 47 healthy pregnant women and 39 preeclamptic patients were examined. Subjects within each group were matched for the gestational age. It was found that RBC aggregation increases with the gestational age in healthy pregnancy and further increases in preeclampsia. Addition of low-molecular weight dextran (MW = 9300) to blood samples of both healthy pregnant women and preeclamptic patients reduces RBC aggregation in a concentration-dependent manner. The obtained results indicate alterations in plasma composition as the primary factor for the increased RBC aggregation in both normal and pathological pregnancy. It is suggested that adsorption of low-molecular weight dextran on the RBC membrane reduces the surface concentration of plasma bridging molecules thereby reducing RBC aggregation toward normal.
Abstract: On 17 August 1999 at 3:04 a.m., an earthquake of 7.4 magnitude (Richter scale) struck the Marmara region in Turkey. The city of Adapazari suffered 2,680 fatalities with approximately 5,300 injured. The Israeli Defence Forces (IDF) field hospital arrived at Adapazari, on day four after the quake. The team consisted of 102 personnel. The field hospital acted as a secondary referral centre. A total of 1,205 patients were treated in the field hospital between day four and day 14 of the earthquake. The frequency distribution of the medical problems seen in the field hospital was 32 per cent internal medicine, 13 per cent general surgery including plastic, 21 per cent orthopaedic surgery, 23 per cent paediatric disease, 10 per cent obstetrics and gynaecology and 1 per cent major psychiatric disorders. A mean number of 35 patients per day were hospitalised in the field hospital for between 24 hours to one week. The rapid establishment of the field hospital enabled the local medical facilities to 'buy time' in order to organise and restore surgical and hospitalisation abilities in this disastrous situation.
Abstract: QUESTION: One of my patients is currently 14 weeks pregnant. She is a teacher in grade 1, and there is an epidemic of Fifth disease in the school where she teaches. Can this disease affect her pregnancy and how should I care for her? ANSWER: Erythema infectiosum (Fifth disease) is usually a benign disease for children and mothers, but might have serious consequences for a fetus due to hemolytic anemia, although the risk is very low. You should evaluate the mother's immune status. If she is already immune (IgG positive), the risks are nil. If she is not immune (although the risk of the fetus's being affected is very low), fetal surveillance by repeated ultrasonographic examination and immune status reevaluation has been recommended. If a fetus is found to be affected, intrauterine evaluation and treatment are available at tertiary care centres.
Abstract: The objective of this project was to establish a measurable process of continuous quality improvement of health care services in the Israeli naval primary care clinics. All navy clinics were surveyed at 6-month intervals. The quality of medical recording was evaluated, and instructive workshops were given on the matter. Real-time physician-patient interactions were evaluated, and immediate feedback was given to the examining physician. Complementary medical services were evaluated and steps toward improvement were taken. A total of 1043 medical records were examined. A general improvement in medical-record documentation (from a score of 6.0 +/- 2.5 to a score of 7.4 +/- 1.9, P < .001) was demonstrated during the first 3 years of the project. No significant change was noticed in the physician-patient interaction score. Complementary medical services improved from a score of 4.9 +/- 1.5 in 1994 to a score of 7.4 +/- 0.9 3 years later (P < .02). This project achieved a significant improvement in the quality of medical recording and of complementary medical services.
Abstract: The primary care clinics of the Israeli Defense Forces are similar to those of the civilian health system, yet some characteristics are unique: Soldiers are a young, healthy population; their physicians are either serving in the reserves for short periods, or are primary care physicians of the regular army; and during military service the soldier is usually treated in several different primary care clinics. A detailed medical record facilitates communication between the various primary care physicians. As part of a 2-year quality assurance project all naval clinics in Israel were surveyed at 6-month intervals. From the clinic records, 685 encounters involving the 7 most common problems were randomly chosen. We evaluated the quality of the medical records of these encounters scoring them according to subjective, objective assessment and therapeutic and evaluative plan (SOAP) Each record was evaluated by 2 physicians and scored from 0 to 100, using fixed criteria. The score for the therapeutic and evaluative plan was significantly higher than that of the other parts of the medical record (80% vs. 55-59%, p < 0.001). The score of the primary care physicians was significantly higher than that of physicians of the reserves (73% vs. 63%, p < 0.001). Encounters involving upper respiratory tract infections and abdominal pain scored higher than those involving other common problems. The medical recording process has a fundamental role in medical care. Our findings suggest that the subjective, objective and assessment parts of naval medical records need improvement. Further studies might help improve the quality of primary medical care.
Abstract: The epidemic of human immunodeficiency virus (HIV) is now affecting populations that were less susceptible in the early 1980s. It is estimated that 8% of patients with AIDS in the US are women in the reproductive age, and 1% are children. In Israel up to 1992, 134 women and 14 children of infected parents were reported as carrying antibodies against the virus. A pregnant women who was a carrier prompted us to formulate various questions as to how the infection affects pregnancy and vice versa, proper management at delivery, rate and modes of perinatal transmission, risk to health care workers, and legal aspects of HIV infection in Israel.
Abstract: A 20 year old male naval crew-member suffering from sea sickness was treated with transdermal scopolamine (TS). After 5 months of continuous treatment, he developed scopolamine intoxication followed by the appearance of recurrent classic migraine attacks. He had never suffered from headache or migraine prior to TS intoxication. The migraine attacks comprised a prodrome of apathy, bad mood and loss of appetite lasting several hours. An aura of scintillating spots, left arm numbness and paresthesias lasting several minutes was followed by a severe throbbing unilateral headache with photophobia, sonophobia and nausea. After one year of repeated follow-up examination, he continued to suffer from the attacks once every 10 to 14 days, with no identified precipitating factors. We are not aware of similar cases in the medical literature. Although it is not possible to establish TS intoxication as a causal effect of the appearance of classic migraine in our patient, the temporal association and clinical course are very supportive of this assumption. Central nervous system neurotransmitter imbalance of cardiovascular alterations may possibly be implicated.
Abstract: Amebic liver abscess responds readily to appropriate therapy, but diagnosis may be difficult. In the case described, the patient's signs and symptoms were atypical, suggesting a hematologic malignancy. The correct diagnosis was made only after ultrasound revealed a mass in the liver.
Abstract: The scheduled appointment system in primary care clinics became popular recently in Israel. Failed appointments created a problem for the doctors, patients and the clinic in Netivot. During 11 months, 2.317 appointments were surveyed. The survey showed 36% of failed appointments, with a decrease to 28% one year later. Rates of failed appointments were 38% for the paediatric population, 35% for adults, and 34% for pensioners. Market days and holidays predisposed to more failed appointments, representing community customs. The presence of a chronic disease that needed follow up ensured a higher rate of attendance (76%), especially among the paediatric population (92% attendance rate). By contrast, a geriatric patient with an acute disease had difficulty attending the clinic (only 16% attending). 512 people (35% of the population) were responsible for the 827 failed appointments, and among them only 12% of the population accounted for 59% of the failed appointments. These findings have important implications in the planning of an appointment system in an urban health centre, and they strengthen the assumption that a small number of patients cause a large number of failed appointments.
Abstract: The scheduled appointment system in primary care clinics became popular recently in Israel. Failed appointments created a problem for the doctors, patients and the clinic in Netivot. During 11 months, 2,317 appointments were surveyed. The survey showed 36% of failed appointments, with a decrease to 28% one year later. Rates of failed appointments were 38% for the paediatric population, 35% for adults, and 34% for pensioners. Market days and holidays predisposed to more failed appointments, representing community customs. The presence of a chronic disease that needed follow-up ensured a higher rate of attendance (76%), especially among the paediatric population (92% attendance rate). By contrast, a geriatric patient with an acute disease had difficulty attending the clinic (only 16% attending). 512 people (35% of the population) were responsible for the 827 failed appointments, and among them only 12% of the population accounted for 59% of the failed appointments. These findings have important implications in the planning of an appointment system in an urban health centre, and they strengthen the assumption that a small number of patients cause a large number of failed appointments.
Abstract: A cohort study investigated the specific outcomes of a health education coursed carried out by recently graduated physicians in an urban primary care setting in Israel. Questionnaires were used to study the effects of the programme on knowledge and awareness concerning antibiotic usage. The results showed a significant gain in knowledge about the causes of infectious disease, appropriate duration of antibiotic intake, side effects of antibiotics and the importance of compliance. In contrast with other studies, low income blue collar workers with less than high school education showed the most significant gains from the programme. Inexperienced physicians were able to implement a community health education programme with clearly defined goals.
Abstract: Ultrasonography of submandibular masses in infancy may be performed during the acute phase of the disease, rapidly providing information about the mass. Further steps in management follow as illustrated by our infant with submaxillary sialadenitis and a non-opaque calculus.
